Patient Decision Support Tools: Potential Options

• Patient decision support tools have been developed using a range of formats, including text, audio, video, and online/interactive platforms.• Decision support tools for diabetes treatment options delivered by community health workers have been shown to improve patient satisfaction (Heisler, et al., 2014)• The Agency for Health Research and Quality is currently studying decision aids for advance care planning, some of which are intended for use by clergy, attorneys, and social workers (Butler, et al., 2014)• Regardless of the format selected, decision support tools should be checked to confirm that they are appropriate to the health literacy level of the patient.

Patient decision support tools have been developed using a range of formats, including text, audio, video, and online/interactive platforms. Some of the tools are designed to be completed by patients before a clinician visit, while others are intended to be used jointly during the visit. The selection of a decision support tool will need to account for the availability of validated tools, patient abilities, preferences, and learning styles, and clinician or health coach familiarity with the tool. For tools to assess the technical quality of a decision support tool please see the next section of this toolkit.

Patient decision support tools have traditionally been used within the confines of the patient-practitioner visit, but research about their use in non-clinical settings and by non-traditional practitioners is being conducted. In particular, the use of decision support tools for diabetes treatment options delivered by community health workers have been shown to improve patient satisfaction (Heisler, et al., 2014). The Agency for Health Research and Quality is currently studying decision aids for advance care planning, some of which are intended for use by clergy, attorneys, and social workers (Butler, et al., 2014).

Addressing Health Literacy

Regardless of the format selected, decision support tools should be checked to confirm that they are appropriate to the health literacy level of the patient. One resource for this is the Agency for Healthcare Research and Quality’s Health Literacy Universal Precautions Toolkit. International Patient Decision Aids Standards (IPDAS) also provides five evidence-based principles for ensuring decision aids are appropriate for users with lower health literacy:

Present essential information by itself or first

Present numerical information in tables and/or pictographs rather than in text only

Present numerical information so that the higher number is “better.”

Beyond health literacy, decision aids may also need to be checked for cultural competency and appropriateness. Because most decision aids have been developed primarily in American or Western European settings, it may be necessary to tailor decision aids in order to address cultures with different health beliefs, attitudes, and preferences for receiving information (Alden, et al., 2014).

Text

Written decision support tools are often in the form of a booklet or worksheet. Written decision support tools range from brief one-pagers to lengthy guides with hundreds of pages. For a given condition or choice, there may be multiple written decision support tools that have been created by different organizations. For example, shared decision making researchers at Dartmouth have created OptionGrids (figure 4), which address a variety of conditions and are available in PDF and interactive formats on the Dartmouth website.

Figure 4: OptionGrid: Prostate Specific Antigen (PSA) Test

Audio & Video

Audio and video decision support tools have become increasingly common. Due to the production costs, many of these tools are proprietary (e.g., Health Crossroads® DVDs). Some shared decision making video tools are available in the clearinghouses detailed later in this toolkit, or on platforms like YouTube.

Interactive

There has also been substantial growth in the creation and use of interactive decision support tools. These tools present information while also eliciting and recording patient values and preferences. In some cases the information can be customized to present individualized risk assessments, such as with the Mayo Clinic’s Statin Decision Aid (Figure 5). Many of the decision support tools included in the Ottawa Hospital Research Institute clearinghouse have interactive options. Some of the interactive tools are designed to be used in the context of a clinician office visit, but others are intended for independent use by patients and generate a summary guide that can be used to facilitate or direct discussions with providers.

Figure 5: Statin Decision Aid Example

The formats of decision support tools are varied, as are the settings in which they are used. Traditionally, decision support tools have been created for one-on-one interactions, usually in the context of a primary care clinic visit. However, other tools have been designed for non-traditional settings, such as the Mayo Clinic Chest Pain Choice Decision Aid for use in emergency departments. A randomized control trial of this tool in low-risk patients presenting to the emergency department with chest pain demonstrated an increase in patient knowledge and a decrease in observation unit admissions and stress testing after patients had ruled out for myocardial infarction (Hess, et al., 2012).

There is also emerging evidence that shared decision making can be done in the context of group visits. Trials of group visits for shared decision making have been performed for patients with stable coronary artery disease (Dontje, et al., 2013), and group visits for women contemplating breast cancer screening are currently being studied.

Use Outside the Clinic Appointment

Traditionally, decision support tools have been created for one-on-one interactions, usually in the context of a primary care clinic visit. However, other tools have been designed for non-traditional settings, such as the Mayo Clinic Chest Pain Choice Decision Aid for use in emergency departments. A randomized control trial of this tool in low-risk patients presenting to the emergency department with chest pain demonstrated an increase in patient knowledge and a decrease in observation unit admissions and stress testing after patients had ruled out for myocardial infarction (Hess, et al., 2012). There is also emerging evidence that shared decision making can be done in the context of group visits. Trials of group visits for shared decision making have been performed for patients with stable coronary artery disease (Dontje, et al., 2012), and group visits for women contemplating breast cancer screening are currently being studied.